Psychological Disability Documentation Form

PSYCHOLOGICAL DISABILITY DOCUMENTATION FORM

The student named below has requested services from the Office of Disability Services (ODS) at Marquette University. In order to determine this student's eligibility for reasonable and appropriate accommodations, we ask that you provide us current and comprehensive information attesting to the student's disability and documenting the functional impact of the disability. The information you provide will be kept in the student's confidential file in ODS.

In addition to the requested information sought from this form, please attach copies of any test results or evaluations conducted as part of your diagnostic process.

Name of Student: ______Birth Date: ______

1.  Do you see this student on a regular basis? ____ Yes____ No

When was your last contact with this student? ______

2.  What is your DSM-V diagnosis for this student?

3. Please check which of the skills listed below are substantially limited because of the student's

disorder.

* Substantially limited is defined as a "significant restriction in the condition, manner, or duration in

which a major life activity is performed compared to most people."

1) Time management _____

2) Organizational skills (physical and/or cognitive) _____

3) Task persistence _____

4) Memory skills _____

5) Reading (fluency, comprehension) _____

6) Quantitative skills _____

7) Written expression _____

8) Employment/work skills _____

9) Self esteem/social skills _____

10) Concentration _____

11) Other _____

4. What methods or testing instruments did you use to arrive at your diagnosis?

o  Structured or unstructured clinical interviews with the individual

o  Interviews with other individuals

o  Developmental history

o  Medical history

o  Neuropsychological / Psycho-educational testing

o  Date(s) of testing? ______Copy of testing results attached? ____Yes ____No

o  Standardized or non-standardized rating scales

o  Other (please specify)

5. What medications have been prescribed for this student?

Medication/dosage:

Date first prescribed:

If the student is on medication, what functional limitations does the student encounter?

______

6. What accommodations do you recommend for this student?

______

7. Will the student's disorder require absences from class? ____ Yes ____ No

If yes, please indicate the reason. *

______for symptoms experienced

______for side effects of medication or treatment

______for treatment of the disorder

* Please note - There may be limitations on the number of absences a student is allowed based on class

requirements.

8. Is there anything else you would like us to know about this student?

______

______

______

______

Please sign, date and return to our office. Thank you for your assistance.

______

Signature of Treating Professional Date

______

Professional's Name (printed) and Title License Number

______

Telephone Number

______

Address Fax Number

1

Office of Disability Services Marquette University P.O. Box 1881 Milwaukee, WI 53201

Phone: 414-288-1645 Fax: 414-288-5799

ODS 07/2014